By Felice L. Gersh, M.D.
The statistics around PCOS, or polycystic ovary syndrome, are pretty staggering: It’s estimated that up to one in ten women are affected by it, and roughly half of women with the condition are undiagnosed. It’s also one of the most common forms of infertility.
Ob-gyn Felice L. Gersh, who is both board-certified as an obstetrician and gynecologist and trained in integrative medicine, sees a lot of women in her practice struggling with both PCOS and infertility. Below, she explains how some diet and lifestyle changes have the potential to radically reduce the severity of PCOS and its symptoms.
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A Q&A with Felice L. Gersh, M.D.
Q: What is PCOS and how is it diagnosed?
A: Polycystic ovary syndrome is the most common endocrine dysfunction of reproductive-aged women. It may be present in childhood and remain present through all of a woman’s life. The obvious symptoms will not manifest at those early and late times of life, yet the metabolic abnormalities will still be present.
In early childhood there are metabolic abnormalities which might manifest as persistent “baby fat.” But that’s all that is seen until puberty, when metabolic and hormonal abnormalities develop, particularly if a girl has an unhealthy diet and lifestyle.
PCOS is typically diagnosed if a woman has at least two of the following:
- Irregular or absent menstrual periods.
- Signs and symptoms of elevated androgens, which are the male-type hormones DHEAS and/or testosterone. Symptoms include: androgenic alopecia, which is male-pattern baldness, or overall thin hair; severe cystic acne; hirsutism, which is male-pattern facial or body hair.
- Polycystic ovaries on ultrasound. This means you have many very small cysts located around the outside rim of the ovaries.
Women with PCOS also have a very high incidence of obesity. About 50 percent are estimated to be overweight and obese. Fundamental metabolic issues make it very, very hard for women with PCOS to lose weight. They’re typically very good at storing and making fat and very bad at burning fat, and it’s usually quite frustrating because some of them eat so little.
The unique problems of women with PCOS are not addressed enough in research, or in the larger conversation, and treatment is often very symptom-based. PCOS has many different manifestations, which is why it often gets misdiagnosed or under-diagnosed: Whatever symptom the woman herself perceives as her biggest problem often ends up determining what type of doctor she chooses to see. If she has irregular cycles or fertility problems, she may go to the gynecologist. But, if her biggest problem in her mind is that she has cystic acne, she may go to a dermatologist. If she has sleep problems or anxiety or depression, which is very common, she may end up going to a psychiatrist. If she has a lot of gut problems, like irritable bowel syndrome, or acid reflux, she may end up going to a gastroenterologist. Those clinicians, unfortunately, may not see the whole picture.
Q: How early can PCOS develop?
A: There is some research to suggest PCOS is a condition that can evolve in utero, and that it’s present at birth. In some women, it may develop in early childhood, and is linked to the presence of endocrine disrupters, chemicals like BPA, that disrupt a normal hormonal environment.
I consider it a pediatric condition that many pediatricians are unaware of. You can screen at-risk girls—those with a family history of PCOS—when they’re quite young, as early as age seven, for a hormone called adiponectin. That particular hormone is associated with burning fat and creating energy. When you have high levels of adiponectin, then you’re capable of burning fat and creating energy. When you have low levels, you’re not. If their adiponectin levels are low, then they have a high risk of developing PCOS. You can be extra careful to avoid environmental toxins, endocrine disruptors, and of course, the Standard American Diet.
Q: Does it matter, for your fertility, when you’re diagnosed?
A: It probably doesn’t matter if you eat lots of organic vegetables, and you exercise and sleep according to our natural rhythms, and you have adequate levels of vitamin D. You know, if you live the “perfect” life, then it doesn’t matter because you’re probably doing quite well already.
If you’re eating a lot of processed food, and not a lot of vegetables, you’re not getting the proper nutrients to run the machinery of the body properly. Women with PCOS are usually inflamed. Even thin women with PCOS—the approximately 20 percent who have what we call lean PCOS—are inflamed. If you get your diagnosis early, you can be very proactive and possibly radically reduce the severity of PCOS from an early age through diet and lifestyle modifications. You can’t prevent it altogether, but you can certainly dramatically reduce the severity.
Q: What’s the emotional component?
A: Not one PCOS symptom is the woman’s fault. Not one. And yet, women with PCOS often have a lot of social isolation and shame. Often they go to doctors who say, “Well, why don’t you just eat less,” insinuating that they’re all gluttons and they’re eating terribly or they have bad hygiene or they’re doing something that’s causing their problem—when it’s really a metabolic and hormonal dysfunction.
We live in a world that inundates everyone with processed foods, chemicals, and endocrine disruptors—toxins that interfere with the hormonal functioning of our bodies. For women who have this disease, those conditions wreak havoc.
Q: What’s the deal with Spironolactone?
A: Spironolactone is a drug that can help some women with their PCOS symptoms. It’s a diuretic used to treat high blood pressure and heart failure that happens, as a side effect, to block the testosterone receptors in the skin. So for some women, it can help with the acne and hirsutism caused by PCOS. I’m not against the use of Spironolactone in women who have high testosterone—it can be really helpful for certain symptoms. But it’s not addressing the underlying problem, and that’s what we want to do in integrative medicine and functional medicine. We want to know what is causing the problem and work on that level if possible rather than just addressing the most prevalent symptom.
So for some women, it can help, but it may also cause birth defects, so it has to be used with great, great care.
Q: What’s happening when a woman with PCOS is having infertility
A: Women with PCOS tend to have very irregular, sometimes absent cycles. So the most obvious thing, often, is that she isn’t ovulating.
A woman’s menstrual cycle is really a vital sign of her health. If she’s not ovulating, or having regular cycles, then there’s something wrong and we need to go look for what that is. Women with PCOS tend to have nutrient deficiencies, chronic inflammation, and insulin resistance. All of these things hamper the ability of a successful fertilization of an egg and a successful pregnancy.
Often, doctors who run IVF centers tell women with PCOS to just lose weight to increase their chance of ovulating. Unfortunately, sometimes quick, small weight loss—usually through deprivation, which is never good—works, but women with PCOS have high rates of miscarriage and complications during pregnancy compared to the average population. It’s really critical to try to slow down and treat the underlying causes of PCOS before attempting to get pregnant.
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Q: What is the treatment?
A: We want to institute the same healthy lifestyle measures whether women with PCOS are trying to get pregnant or not. Small steps are the best place to start. Don’t let the best be the enemy of the good, as they say.
DIET: I promote a very high-fiber, plant-based diet, which I find most effective for lowering insulin resistance. It also happens to be a great tool to help women to reduce inflammation, get the nutrients they need, and lose weight if they’re overweight. Here are some general guidelines and places to start:
- Try to stop eating processed foods. Start by eliminating all foods with high fructose corn syrup. I say if you couldn’t eat it a thousand years ago, try to avoid it.
- Eat across the colors of the rainbow, because vegetables are like magic food. They have a lot of antioxidants and polyphenols, which actually help communicate with the microbes in our gut to support our health. Women with PCOS are in a state of oxidative stress, which is why they really do well with a diet full of antioxidants.
- I think a little bit of healthy animal protein is good, but it should not be a lot. We tend to overeat protein as adults. I actually prefer patients go vegan for the first few months of treatment if they’re willing, or as much as they’re willing, so the focus is on tons of vegetables. If they’ll eat nine to twelve cups of vegetables a day, of all kinds, that’s ideal.
- I know it’s expensive, but try to buy organic fruits and vegetables where you can—it’s really very important to not have chemicals in our foods.
- I like people to try to focus, if they can, on eating their biggest meal in the early part of the day. In my practice, I’ve found that women who eat about two-thirds of their calories for breakfast, one-third for lunch, a very small dinner—and then fast for about 13 hours or so overnight—see decreased insulin and testosterone levels over time.
STRESS: Women with PCOS have a dysregulated sympathetic nervous system, which makes them more prone to anxiety and stress. There are many lifestyle things that we can do to address that. I love guided imagery. We introduce them to mediation. I encourage everyone to get out in nature and touch their body to the earth. Of course we work on getting plenty of sleep, too. Women with PCOS often have problems with their melatonin as well, so we want to address that.
EXERCISE: With PCOS, we have to be very cautious because patients are often quite inflamed and they can be prone to injuries. In my practice, we go very slowly. In the beginning, we’ll do some resistance training and we will also get them in a walking program or on an elliptical.
It’s important to start to exercise regularly, but for women with PCOS, an effective fitness program can be as simple as power walking. You can do power walking and really get a very good workout and you’re not likely to injure yourself.
Q: What’s your advice for finding a doctor who understands PCOS?
A: It really pains me to say this, but some conventional ob-gyn’s will simply prescribe birth control pills or Spironolactone or an insulin-sensitizing drug called Metformin. Or send the patient to an endocrinologist who might do the same. They often don’t address the underlying issues that really plague women with PCOS. They just try to cover up some of the symptoms.
So it can be quite a search to find someone who will help treat your PCOS holistically. There are some good resources who you can contact to see what doctors they recommend in your area. If you can, try to find a functional medicine doctor who will work with you to implement effective lifestyle changes and take the time to understand what you need.
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Felice L. Gersh, M.D. is board certified in both ob-gyn and integrative medicine, and is the medical director of a practice dedicated to the special health needs of women, the Integrative Medical Group of Irvine, in Irvine, California.
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